Four months ago, Alas Wallace knew she needed to make a change. The 22-year-old was pregnant with her fourth child, and she didn’t want to raise the newborn in her hometown of Jacksonville, Florida.
The city had too much history — too many memories she wanted to leave behind.
With a baby on the way and three toddlers in tow, Wallace packed up her belongings and moved in with a cousin in Macon. By December, she’d left her cousin’s place and was staying at a homeless shelter.
Wallace is one of many young parents across the country who has experienced homelessness.
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Young parenthood affects homeless women at disproportionate rates. More than 40 percent of 18- to 25-year-old women who have experienced homelessness in the past year are either pregnant or already a parent, according to a national survey by Voices of Youth Count, an organization that tracks youth homelessness.
The unstable living conditions that accompany homelessness can pose health risks for pregnant women and their children, especially in a state like Georgia.
Georgia consistently falls to the bottom of national rankings for maternal and infant health care for its high mortality rates and shortage of providers, especially outside of major metropolitan areas. The state has the third-highest maternal mortality rate, with 46 deaths for every 100,000 live births, and fifth-highest infant mortality rate, with nearly eight deaths per 100,000 live births, according to America’s Health Rankings’ 2018 report.
Barriers to health care affect pregnant women and infants across the state, from rural towns to bustling urban hubs. For pregnant women experiencing homelessness, access to prenatal and infant care can be particularly difficult to reach.
“There’s a lot of room for improvement for how we provide service,” said Dr. Keisha Callins, an OB-GYN who works with low-income patients in Middle Georgia.
‘I just needed to do it on my own’
Wallace spent most of her childhood in foster custody, while her mother battled severe schizophrenia. Between ages 8 and 19, Wallace passed through more foster homes than she could count. She was still living in a group home when she became pregnant with her first child.
Studies have found that teens in the foster system face higher pregnancy rates than their counterparts not in state custody.
As Wallace’s parents cycled in and out of her life, she struggled to trust them.
“I didn’t know how to cope with everything that I was going through,” Wallace said. “It took me until I had gotten older and received a bunch of counseling for me to understand everything that I was going through.”
Wallace is still close with her parents, despite their years apart. But after living with relatives in Jacksonville for the past few years, she decided she wanted a fresh start.
“I came to Macon to get away from everything and everybody, ‘cause I just need to focus,” she said. “I just needed to do it on my own.”
Far from the weight of her past, Wallace felt relieved. But her cousin’s home was small, and Wallace didn’t want to overstay her welcome.
Seven months pregnant, Wallace sent her kids back to Florida to stay with family for the holidays, then moved herself into the Salvation Army women’s shelter. It wouldn’t be a long stay, she told herself. Just enough time to find a steady job and a stable home.
With help from the shelter’s director of social services, Naomi Ladson, Wallace set goals for herself and checked them off one by one.
After a month at the Salvation Army, Wallace secured a warehouse job that paid $14.95 an hour and a three-bedroom, two-bathroom mobile home in south Macon.
Before coming to the Salvation Army, Wallace had struggled to get by on her own.
Pregnant women who meet certain income requirements qualify for Medicaid, but it took Wallace almost three months to get coverage. Medicaid can bill retroactively for up to three months of care received before coverage kicks in, but in the meantime, Wallace had to pay for all of her prenatal care out of pocket.
She said she spent between $200 and $350 in copays for each doctor’s appointment, and also had to budget in the cost of vitamins and prescriptions, all on a limited income. At the start of her pregnancy, Wallace had appointments every week. The bills quickly added up.
“It got frustrating,” she said.
The young mother was determined to get the care her baby needed, though, even if she had to set aside every last dollar from her paycheck.
Barriers to care
Callins, the Macon OB-GYN, knows how difficult it can be for women experiencing homelessness to access prenatal and postnatal care. The doctor practices at Community Health Care Systems, a federally qualified health center that receives funding from the federal government to treat low-income and underserved patients.
Many of Callins’s patients struggle to find transportation to their appointments or have rigid work schedules that limit their availability.
Homelessness adds a new level of barriers to women’s health care beyond what other low-income women may face, she said. Patients experiencing homelessness often hesitate to share information about their housing situation with their doctor fearing judgment.
It’s up to the physician to ask the right questions and pick up on subtle cues to ensure the patient can access the help she needs, Callins said. Otherwise, women can fall through the cracks.
Prenatal care follows a strict schedule, with more than a dozen appointments to track the baby’s process over the course of the pregnancy. Without a reliable phone number or address, it can be hard to get in contact with patients and remind them about upcoming appointments, Callins said.
She once lost touch with a patient for two months.
After falling out with her family, the patient had nowhere to go and spent her nights in a structure with no running water or electricity. The patient came to see Callins several months into her pregnancy, then disappeared.
Only when she was arrested and incarcerated for a minor stealing offense could the doctor give her patient the consistent treatment she needed.
“I think that is the first time where homelessness really slapped me in the face,” Callins said. She felt conflicted. “I would never wish incarceration on anyone, but I didn’t have another reliable way for me to be able to take care of her.”
Once the patient was released, Callins said she disappeared yet again.
Callins and a team of social workers visited shelters around Albany, where she was working at the time, with no luck. Nightmares about the patient and her baby kept the doctor awake at night for three weeks.
When the patient checked into the hospital one day, thinking she might be in labor, Callins was overcome with relief.
“I was like, ‘Even if she’s not in labor, I’m keeping her until we deliver this baby,’” she said.
The doctor knew her patient had miscarried before, and she didn’t want her to lose another baby.
“I did feel like I had to show extra care and concern, and, you know, try to get her to realize that despite her situation, we were gonna get through this,” she said.
After months of lost sleep, Callins delivered a healthy baby for the patient.
The story had a happy ending, but it opened the OB-GYN’s eyes to the many gaps in pregnancy care for homeless patients. And those gaps can have dire consequences.
If patients can’t come in for regular appointments, Callins said, doctors miss important milestones that warrant screenings and tests. It also can be difficult to provide follow-up care if problems in the pregnancy arise.
“Not having a stable place does really impact the care that they receive, the care they can access,” she said.
An updated approach to prenatal care could better serve such a vulnerable patient population, she said.
The key is increased education, she said.
“I have people who should have come in who were in preterm labor and didn’t know that it’s not normal for you to not feel your baby move or not normal for you to have that education, which could come from regular prenatal care, regular interactions with your provider who could say, ‘OK, if this happens, then do this. If this happens, call me. If this happens, go to the hospital,’” the doctor said.
Women aren’t always aware of the free and affordable resources readily available in the community. Most prenatal and postnatal health care needs can be met at the local health department, said Judy McChargue, district immunization coordinator and interim county nurse manager for the North Central Health District.
The Macon-Bibb County Health Department has its own prenatal clinic, which offers pregnancy testing, prenatal education, well-checks and other support services for expecting mothers. The health department also provides prenatal vitamins and prescriptions, which can improve health outcomes for both mothers and babies.
But if women don’t know those services exist, Callins said, they risk worse outcomes.
“We have the resources, but we have to help people utilize the available resources,” she said. “And we are lacking in how we encourage utilization.”
A first step
After more than a decade in foster care and three years bouncing between relatives’ homes and the Salvation Army, Wallace is ready to start a new chapter. The young mother just moved into her first home, in a small mobile home park off Hawkinsville Road.
It’s not a forever home, but it’s a first step, she said.
Wallace moved in just after New Year’s, and she’s hoping to get everything set up before the baby is born in February. Her three other young ones have already filled their bedrooms with colorful picture books and fuzzy stuffed animals.
Wallace said she loves how quiet the area is, and she’s happy to have a bit of extra space to herself. She also is relieved she no longer has to wait outside in the cold all day, like she did when she was staying at the shelter.
“This new home is the start of basically a new beginning for all of us — for me and my kids,” she said. “And I know it’s not going to be the most fanciest home, because it’s our start-off home for the time being. And then, from there, I’m just going to keep working my way up.”
Samantha Max is a Report for America corps member and reports for The Telegraph with support from the News/CoLab at Arizona State University. Follow her on Facebook at https://www.facebook.com/smax1996 and on Twitter @samanthaellimax. You can also join her Facebook group. Learn more about Report for America at www.reportforamerica.org.